• Andree Daphnee Renaud.

This week clinical experience has afforded me to understand that every practitioner that works with children needs to be a detective with great assessment skills. 

• My challenge this week was to differentiate between appendicitis and gastroenteritis in a toddler.  One way I overcome this challenge was by paying attention to my preceptor clinical skills, and I was able to come up with the right diagnosis.  The other challenge I had was handling an agitated 10-years old patient with autism. This patient was agitated, and no matter what I did, I could not calm her down at first. This has been a challenge for me, and I had to use verbal de-escalation techniques to finally calm the patient.  One of my successes was I feel complete now on how to approach different developmental group age by providing them with toys, and by discussing children's movies with them before doing their assessments and history taken.  

           R.R., a 17-year-old Hispanic female who presented to the clinic with a chief complaint of “I cannot control my blood sugar.”  The patient reported excessive thirst, increased hunger and fatigue, and frequent urination.   A comprehensive history was done for this patient.  The patient reported of being diagnosed last year with Type 2 diabetes.  The patient stated that she is physically inactive and eats unhealthy food.  She further added that she rarely takes her anti-diabetic medications.  

Assessment

Her BP was 120/70 sitting, temperature 98.2 degrees Fahrenheit orally, Height 64 inches tall, Weight 64 kg and her BMI was 24.39. Her heart rate was 102, and her respiratory rate 18.  

Blood sugar levels 280mg/dl.

Dry skin

Keep going to the bathroom

Tired looking

Fruity breath odor

Patient lost 4.8 kg from last visit

Primary diagnosis

Hyperglycemia

•            The patient presented with polyuria, polydipsia, and fatigue, which conclude a diagnosis of hyperglycemia.  According to Etingin (2017), other signs of high blood sugar include increased thirst and urination, headaches, fatigue, blurred vision, and a "fruity" smell to his breath.  Comprehensive evaluation reveals that the patient has type 1 diabetes.  Type 1 diabetes occurs due to insulin deficiency in the body.  Since she was diagnosed last year, the patient has had diabetes, making this the most appropriate diabetes.  A urinalysis that was done revealed ketonuria.  Ketonuria is common in type 1 diabetes due to ketone bodies (Kim et al., 2019). 
• Differential Diagnosis
• Metabolic Syndrome
•            According to Sapkota et al. (2020), metabolic syndrome is present, although in low numbers in young adults putting them at risk to develop diabetes in the near future.  Early assessment of metabolic syndrome and diabetes’ risk in young adult may provide insights for preventive and control plans for risk population
• Plan of Care
•            Patient to continue with 500 mg of Metformin bid PO for blood sugar given with meals.  A follow-up visit will be done in two weeks to discuss HgA1C, patient will be referred to an endocrinologist.  Then, the patient will be evaluated for need of insulin.  Patient referred to counselor for medication compliance, referred to nutritionist for weight management and dietary intake.
• Patient Education

           Physical activity and diet are important in the management of diabetes.  The patient will be advised on proper dietary intake.  This will include low-fat intake, whole grains, legumes, vegetables and fruits (Raveendran, 2018).  Regular exercises will be important.  The patient will be advised to do at least 30 minutes walking daily.  The patient will also be educated on the importance of medication adherence in controlling blood sugar levels, the importance of checking blood sugar regularly. Teach the patient about hypo and hyperglycemia. 

           This experience will be important to me in my future nurse practitioner practice.  My experience this week has revealed the importance of patient-centered care.  I will implement patient-centered care that considers my patients' culture, values, needs, and preferences.

References

Etingin, O. R. (2017, July 1). High blood sugar signs. Women’s Health Advisor, 21(7), 8.

Kim, G., Lee, S., Lee, B., Kang, E. S., Cha, B., Ferrannini, E., Lee, Y., & Cho, N. H. (2019).

           Spontaneous ketonuria and risk of incident diabetes: A 12-year prospective

           study. Diabetologia, 62(5), 779-788. https://doi.org/10.1007/s00125-019-4829-x (Links to an external site.)

Raveendran, A. V. (2018). Non-pharmacological treatment options in the management of

           diabetes mellitus. European Endocrinology, 14(2),

           31. https://doi.org/10.17925/ee.2018.14.2.31 (Links to an external site.)

Sapkota M, Timilsina A, Shakya M, Thapa TB, Shrestha S, Pokhrel S, Devkota N, & Pardhe BD.

           (2020). Metabolic Syndrome and Diabetes Risk Among Young Adult Students in the

           Health Sciences from Kathmandu, Nepal. Drug, Healthcare and Patient Safety, ume 12,

           125–133.